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Student Information |
| - Student’s name |
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- Date of birth |
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| - Age |
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- Gender |
Male:
Female:
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| - Student’s address |
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- City |
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| - Country |
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- ZIP Code |
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| - Phone number |
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- 1st language |
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| - E-mail address |
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Medical Information |
Primary contact |
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| - Name |
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- Relation |
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| - Phone number |
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- E-mail address |
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Secondary contact |
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| - Name |
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- Relation |
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| - Phone number |
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- E-mail address |
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| - Diseases or allergies, past or
present: |
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| - Activities student cannot take part
in: |
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| - Currently on medication? |
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| - If Yes, what kind? |
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2010 Sessions |
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*** By sending this form, you automatically register to
a FLY Experience session.
A deposit of $875 CAD paid by check should
follow. The balance must be paid before June 1st 2010. ***
***Discounts are offered to groups, family members and to all students registered before April 1st of each year.
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Visa card accepted (2% extra charge) |
FLY Experience
1203 du Haut-Bois
Longueuil, Québec
J4N 0A2
Canada |
Any Problems or Questions? Call us: 1-888 532-XFLY (9359)
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